Prostate Cancer

Question for Short Debate

Asked by

To ask His Majesty’s Government what steps they are taking to ensure that GPs proactively discuss prostate cancer with men at the highest risk; and inform them of their right to a free prostate specific antigen test.

My Lords, around one in eight men will be diagnosed with prostate cancer at some point in their lives. In the UK, it is the most commonly diagnosed cancer in men and, sadly, it causes around 12,000 deaths a year. Even more tragically, this number includes many men who are dying needlessly due to late diagnosis. Around one in five of those diagnosed are diagnosed too late. When caught early, there is nearly a 100% survival rate—a remarkable reflection of advances in treatment—but survivability plummets to around 50% when the cancer has progressed to stage 4. Our current approach to testing and screening is falling short. That is why I have secured this debate today, and I welcome Members from across the House who have indicated that they wish to take part.

I support calls for a targeted screening programme for high-risk men. I believe that over 135 Members in the other place have expressed their support, as have many noble Lords. Importantly, so have the vast majority of GPs when surveyed, as well as many patient and campaign groups, including Prostate Cancer Research and Prostate Cancer UK, which I must thank for their support. It is also important to thank the Daily Telegraph and Daily Mail for raising awareness by taking up the campaign.

The National Screening Committee is currently carrying out its review, but it seems clear to me that the introduction of MRI and new biopsy techniques, alongside the traditional PSA test, goes a long way to addressing concerns about the accuracy of a PSA test alone and the risks of the diagnostic process. The All-Party Parliamentary Group on Prostate Cancer published a report yesterday to that effect, highlighting the progress that has been made in reducing the risk of overdiagnosis and overtreatment. I hope the noble Baroness, Lady Merron, can offer an update on when this is expected to conclude and on what the Government are doing to ensure there is no further delay.

I also want to note the longer-term work, including the £42 million TRANSFORM trial, announced under the previous Government, that can further add to the evidence base and is a huge step forward; yet I have not chosen to make this the focus of today’s debate, because the issue is too urgent to wait. I want to focus on what we can do immediately to stop men dying needlessly.

Whatever the outcome of the National Screening Committee’s review, we need to change the guidance we give to GPs. At the moment, we leave it to men to proactively request a PSA test from their doctor and we actually prevent GPs from raising the issue, even with men who are at the highest risk. Men are already more likely to put off a visit to the doctor. I must admit I know this from personal experience. How realistic is it to have a system that means a man must proactively find out his risk and then chase his doctor for a prostate cancer test? It means only those who have sharp elbows or who are highly skilled at navigating the health system are getting the tests they need. It is bad enough across the board, but such an approach also entrenches health inequalities, leaving high-risk groups, particularly black men, those with family history and men in deprived areas, seriously disadvantaged.

My Lords, I thank the noble Lord, Lord Mott, for initiating this debate. Some of my comments are shared by the noble Lord, Lord Winston, on whose behalf I also make them, as he is in hospital with a broken leg—but he is doing okay.

I agree with the comments that the noble Lord, Lord Mott, made about identifying and offering the PSA test for higher-risk patients. My comments are therefore not about GPs’ role in offering the test to men at higher risk of prostate cancer. My comment is mostly based on the use of PSA as a test for screening purposes. It is a test which has a fairly high degree of sensitivity but a very low degree of specificity, which means that the rate of false positives and false negatives is very high for a screening test.

I agree that some of the trials being carried out—the noble Lord, Lord Mott, mentioned one in Royal Surrey hospital, and there are others in Europe and the United Kingdom—may help us modify the guidance that could be given based on the results of the study and therefore could be targeted at a wider group of people. But we need a test that is much more reliable, easily carried out and much more accurate. Such a test as a preliminary study was developed by the Institute of Cancer Research and the Royal Marsden Hospital. It uses a spit test, which recognises 130 different modifications or mutations of DNA with a high degree of specificity, much higher than the PSA, and a high degree of sensitivity. In a model trial, it would have identified nearly 13,000 patients, the same number of deaths that occur per year, with low-grade prostate cancer. It is a test that requires further trials, because it is easily administered and may become part of a wider screening programme. So we need to be much more aware of innovations that may occur.

My Lords, first, the key word in my noble friend’s very important question is “proactively”. Axiomatically, it is Ministers who must decide to be proactive in the end, not national screening committees. This is a time when worried men face a blizzard of news and views about their prostate risk. These are sometimes very hard to decide on; they are conflicting or indeed confusing, even within some GP practices on the front line. PSA tests are valuable, but they have some limitations, not producing infallible results every time. We must be honest about the upsides and downsides, and they must be made clear in order to get realistic buy-in from men on the need to get started on being checked from age 45, or indeed even earlier.

Secondly, surely the messages should be the same in all four parts of the United Kingdom. They are not at the moment: they are different, which strikes me as bizarre, despite the fact that men do and can freely move across borders, just as the condition moves across borders. So I say to the Minister only that in the end it is national Ministers in the four different regions who must be got together to give one national message, lest the tragic death toll climbs further and faster.

My Lords, I thank the noble Lord, Lord Mott, for securing this important debate. One of the lessons of history is that we do not learn lessons from history, and we must not ignore the historical facts. First, prostate cancer is the most diagnosed cancer in men aged over 45 in England. Secondly, there are higher risks of prostate cancer linked to ageing, black men and family history. Thirdly, early diagnosis is critical. Survival is nearly 100% when detected early but drops to around 50% at stage 4. Yet one in five men—that is 10,000 annually—is still diagnosed too late. Fourthly, despite these facts and earlier warning signs, there is still no UK-wide screening programme. So my first question of the Minister is: what analysis of other nations’ prostate cancer treatment is the Government carrying out, and have they come to any conclusions as to the way forward for the UK?

Next, will the Minister set out what action the Government will take to ensure that higher-risk men who request a PSA test are never refused, in line with current policy? What conclusions have the Government reached as to the most effective method of PSA screening as a result of the TRANSFORM trial launched in May of last year? Bearing in mind the reluctance of some men to submit themselves to rectal examinations, what assessment have the Government made of the BARCODE 1 study on the early detection of prostate cancer using saliva samples to identify high-risk patients? Lastly, when will the UK National Screening Committee announce the conclusions and recommendations of the TRANSFORM trial? A national screening programme for men at high risk of prostate cancer is long overdue. National screening will radically improve the fate of prostate before it is too late.

The biopsy was not much fun. Stuck in those stirrups, my dignity dangling in the breeze, a charming lady nurse asked me if I was comfortable. We both agreed that that was a profoundly stupid question and laughed our way through the prodding and the poking.

Prostates raise many questions. I got through it thanks to my GP, Dr James Banfield, and support from others, particularly my noble and very dear friend Lord Kirkham.

Too often, men shy away and leave things too late. We need more encouragement, and perhaps more courage, like that of Sir Chris Hoy. When I was a guest editor of the “Today” programme and devoted it to prostate cancer, I interviewed Bill Turnbull, so full of regrets. He had tried to ignore it. He had only a few months to live. We know it does not need to be that way.

When my turn came, I chose radiotherapy. On day one, I gave the young technicians a large box of House of Lords chocolates. “What’s that for?”, they asked. I told them it was to encourage them to aim straight. That was five years ago. I caught it early, which is the key, not only to an extended life but to one without the mucky, yucky side effects, which is not possible without supportive GPs and timely testing. Testing may not be foolproof, but it is better than being a fool. So I am grateful to my noble friend for this short debate. We are helping save lives.

The Lord is absolutely correct. It was not much fun, was it? I speak as someone who is recovering from prostate cancer. Nearly two years on—so far, so good—I am under active surveillance. I was treated early because of my wise and gentle GP, Dr Nazeer, who has just entered his 60th year in the National Health Service. He gave me his time and his patience, and he cajoled me to rid myself of type 2 diabetes, and after that insisted on giving me an annual blood test. That is how I was diagnosed early.

It is obvious to me that in a civilised society we should allow our GPs to have a conversation with men about what the testing regime should be, particularly those high-risk groups. So I thank the noble Lord for bringing up an important subject that means a great deal to tens of thousands of men and their families in this country, and I know the Minister will have heard very deeply what he had to say today.

My Lords, I give huge thanks to my noble friend Lord Mott for this important debate, and thanks also to the noble Lord, Lord Patel, for pointing out that we need better diagnostics with better specificity and sensitivity. We all aspire to a new generation of diagnostics, but we have to live with what we have today. My noble friend Lord Dobbs pointed out that timely assessment is the most urgent thing if you are developing prostate cancer. That is why I would like to address the question of risk aversion: a culture that, I am afraid to say, holds back timely intervention.

The evidence suggests that, too often, doctors’ intolerance of uncertainty is directly associated with diagnostic delays and errors, sidelining informed choices for patients and instead favouring the psychological comfort of clinicians. The NHS culture too often infantilises patients. In modern life, we are used to making 35,000 decisions a day, so the suggestion that patients cannot handle the complexity of modern tests, the idea that diagnoses may be reversed, or the pressure of diagnosis is, frankly, absurd. Yet studies reveal wild variations in PSA testing between GP surgeries, driven often by individual bias, not by science. This lottery is completely unacceptable.

This is a system-wide problem involving not just prostate cancer. Early detection of disease is vital if we are to turn around our national health disaster. We need risk-based screening, mandatory GP engagement and accountability for delays. Therapeutic privilege should be dead and buried; patients deserve informed choices and agency.

My Lords, as a doctor, I have witnessed many men living with prostate cancer and cared for them. It has been heartening over the last 30 years to see the dramatic improvement in survival—good survival—of prostate cancer. My own husband was treated successfully for an aggressive prostate tumour 17 years ago, following an entirely fortuitous PSA test. But as we have heard and as the noble Lord, Lord Patel, has reminded us, PSA testing is not perfect; surely it will be superseded soon by something better. The 20% reduction in mortality through PSA screening has surely been won very well, but at a very high price in the side-effects of treatment by surgery and radiology, and in urinary incontinence and erectile dysfunction, which very few urological services in the UK take seriously enough to treat, even though they can be successfully treated.

Going back to the PSA test, there are now risk calculators to help GPs and patients assess whether the test is worth it. As has already been mentioned by the noble Lord, Lord Mott, male patients do not go to the GP unless they are forced to and they have symptoms. They do not like to go through the 8 o’clock scramble—how many of us do? We are light-years away, therefore, from the discussions that we need between patients and GPs, even though, theoretically, we have universal registration with GPs, which should be the perfect concept for developing the system. GPs will not do it unless there is money in it, and if we could include proper screening with risk calculators with GPs in the QOF points, we could solve the problem.